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THE ROLE OF THE STAFF CONFERENCE IN A STATE MENTAL HOSPITAL
Pertti JO Pelto
The purpose of this paper is to describe the functioning of diagnostic
and release conferences in a state mental hospital, in order to point out
areas of study that would be of interest to social-science theory as well
as to practical therapeutic programs.
During the summer of 1957 the writer, together with another anthro-
pologist, was engaged in field study at Napa State Hospital, a large mental
hospital located about forty miles northeast of San Francisco, California.
The patient population at the hospital numbers about 5,500, including court
and voluntarily- committed mentally ill, alcoholics, drug addicts, children
committed for "juvenile observation,' and a large number of seniles. The
hospital is not intended for treatment of the mentally retarded or crimin-
ally insane, or for neurotics. Although the patient population has grown
steadily since the hospital was founded in 1871, the past year has shown,
for the first time, a decrease of 160 patients. This has been brought
about by a combination of circumstances, including use of new, so-called
"wonder drugs," as well as by important changes in the social environment
within the hospital. Many of these recent developments reflect increased
state expenditures for personnel, equipment, and services.
During the two months of research at Napa State Hospital the writer
studied medical records of individual patients, observed behavior in wards,
interviewed patients, technicians, doctors, and other personnel, and ob-
served the proceedings of staff diagnostic and release conferences. It
became clear that the staff conferences deserve close study as an Important
focus of hospital decision-making and as a means of expressing value orien-
tations.
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Diagnostic and Release Conferences
Staff conferences are held separately in the men's, women's, and child-
ren's services (administrative divisions). The conferences take place on
Mondays and Wednesdays. While there is some attempt to separate diagnostic
and release conferences, most sessions handle both kinds of cases. The con-
ferences are attended by staff psychiatrists, physicians, psychologists,
social workers, the industrial therapist (at men's conference only), and
various spectators such as student nurses and technicians. Of these people,
all except the spectators express opinions and ask questions during the
conference, but as a general rule only the psychiatrists, physicians, and
occasionally the psychologists, participate in the making of recommendations.
At release conferences the major decision concerning a particular
patient is nearly always whether or not he should be released. A secondary
question is the advisability of the particular Utplan't of release--the selec-
tion of the patient's post-hospital environment.
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The selection of the post-hospital environment depends in most cases
on the initiative of the patient and his relatives. Often there is an
informal agreement (arranged by letter or visit) between the patient and a
relative to the effect that the patient can be signed out to live with that
relative. This plan is then brought to the attention of the patient's ward
doctor, or perhaps to the ward social worker, At this time the ward doctor
decides whether the patient has recovered enough to be considered at the
staff conference. Some ward doctors make a practice of sending to conference
nearly all patients who present a leave replan,"t but most wards have chronic
patients whose recurring '"plans t for leave are only infrequently brought
before conferences because the patient is obviously still mentally ill.
Such chronic *leave-planners" usually succeed ultimately in getting their
proposals admitted to conference, however, since this can ease tensions be-
tween doctor and patient by shifting responsibility to the staff conference.
The procedure in the release conference is usually as follows:
(1) The patient's ward doctor presents background information about the
patient, including social history, evidence of mental illness presented at
time of commitment, diagnosis, record of hospitalization, leave plan of
patient, and statements from family members concerning the request for
release (if there are any). The completeness of this preliminary report
varies considerably with the predilections of the particular ward doctor
and the amount of ambiguity in the case.
(2) The patient is brought into the conference room.
(3)  The doctor who has presented the case usually takes the lead in ques-
tioning the patient concerning his release plans and present mental function-
ing. The procedure of the conference can best be described by giving some
examples.
Case 1: Conference of August 12, 19573
Dr. Smith (the patient's ward doctor) presented the case by reading
from the medical files (quotations are approximate).
.This case is that of a h8-year old married laborer. He escaped from
another state mental hospital, was working for quite a while, then was
picked up andi brought to this hospital.  The diagnosis is schizophrenia,
undifferentiated. This man says that he inhaled powder smoke and that is
the cause of his symptoms. He apparently has had some delusions about
spirits. Maybe his wife will take him back although she has not visited
him. He drinks somewhat, has a ground-parole card, and has made a good
adjustment on the ward."
(Patient is ushered into the room.)
Dr. Smith: *How long have you been here?"
Patient: (Gives correct answer.)
Dr. Smith:  "What is the date today?"
Patient:  "August 12th."1
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Dr. Smith:  "Why are you here?"
Patient: (He tells somewhat involved story about being picked up by the
immigration officers because he is an alien.)
Dr. Smith: "Were you mentally ill?"
Patient:  "Yes."  (He goes on to tell about the noise of wagon wheels
making him nervous.)
Dr. Smith:  "What do you want to do now?"
Patient: (Explains that he wishes to go home to his wife and eight
children.)
Dr. Smith:  "Would she take you back?"
Patient: "Well, yes." (He admits that she has not written or visited
him in the past year and a half.)
Chairman: "Does anyone else wish to question the patient?" (Pause)
"OK, that's all, Mr. C. You may go now."
(Patient leaves the room.)
Dr. Smith: "I recommend indefinite leave of absence to the wife if she
will take him. No overt evidence of psychosis,"
Since there were no dissenting opinions, the recommendation was
adopted and the case was referred to the social worker, who wrote to the
patient's wife. As the wife has not yet replied (3 weeks later), the
patient is still in the hospital. If no word is received from the patient's
wife, his release may be considerably postponed even though he is well
enough to leave the hospital. The family can thus irxnefinitely defer the
release process by their inaction or hostility.
Case 2: Conference of July 24, 1957
The patient in this case was an attractive young divorced woman of
about 25. She had been in the hospital for about eight months, with a
diagnosis of manic-depressive, manic reaction, and had received electro-
shock therapy, a course of drugs, and other treatment. In the later phases
of her hospitalization she had been re-diagnosed as schizophrenic, paranoid
reaction. The commitment papers state that the patient had walked down the
street of a nearby suburb in her negligee, saying that she was the angel
Mary. At the time of the conference she appeared to be in good contact
with reality, and had no hallucinations or delusions.
In response to questions from several members of the staff the patient
stated that she wanted to get a job in dress designing, at which she has
had some training; she would like to live alone, and would take care of her
two small children. She denied any memory of the events that brought about
her commitment. (Such real or simulated amnesia is common among patients
who have had electro-shock therapy.) The patient said that her mother, who
was caring for the patient's children, would soon be going back' to her home
in Denver. Some of the staff members felt that this would be for the best,
because the patient had frequent emotional conflicts with her mother.
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The staff denied the patient's request for release because she did not
appear to be realistic about how much work and responsibility she could
undertake at the present time, and also because there would be no responsible
person at her home to aid and supervise her and help in caring for the
children.
Staff Conference Decisions
The decisions of the staff conference concerning release of patients
appear to hinge on at least four major criteria: (1) Is the patient well
enough to be at large in the community without being a threat or nuisance
to society? (2) Will the patient receive adequate care and supervision in
the community? (3) Will the outside community be of more therapeutic bene-
fit to the patient than is the present hospitalization?  (4) What are the
wishes of the patient and his family?
From our observations of the staff conference procedure it appears that
the chief question to be decided in the release process is almost always
whether or not the patient should be released, rather than what particular
leave "plan" should be adopted. The plan offered by the patient, with or
without the-co"peration of his relatives, is considered (see note 2). If
the staff conference rejects the proposed plan, however, the social workers
may be instructed to aid in the working out of a new suggestion. In cases
where the patient has children, the staff must also decide whether the
patient is well enough to resume responsibility for their care.
The importance of the negative or "no action" decision as an exercise
of the formal power of the hospital can be seen from the following table,
in which almost one-fourth of the requests for leave were denied or deferred
for further planning.
Table 1
Results of 24 Conferences During July-August, 19574
Per
Cases Cent
Discharged outright              5        25     10
Referred for Family Care planning         16      7
Granted leave of absence6                145     59
Referred for further planning             24     10
Release denied                            35     14
Total        245    100
Theoretical Problems in the Release Process
The release process at an eastern state mental hospital has been des-
cribed by Simmons, Davis, and Spencer (1956) as a "classic triangular"
situation. The authors felt that the seeking for consensus among the
patient, the patient's family, and the hospital involved "structured strain"
(the presence of incompatible goals among actors in a social structure),
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which would be of importance in the patient's adjustment to the post-
hospital environment. The authors state that: (1) In cases of disagree-
ments among the three actors, the patient's desires in the matter are
usually granted. (2) If the patient and the family are allied against the
recommendations of the hospital staff, the hospital recommendation is
usually not followed. (3) The hospital commands the most formal power and
the patient commends the least, yet the "latter's wishes are the best pre-
dictor of what the outcome will be." (Simmons and others, 1956:27). (I)
* . the patient has a great deal of informal power in that the hospital
personnel, acting in his interest, will seldom advocate a plan that he
strongly resists. . Ot (p. 27).
Simmons and his collaborators stated that they got their data by col-
lecting the names of patients who had been released from a hospital in an
eastern metropolitan area. "The chief of each service was asked, after
reviewing his case records, to tell us for each patient: his social or
family setting on admission, his social or family setting on release, the
disposition plan favored by the patient, the plan favored by the hospital,
and the plan favored by the patient's family."t (They did not get independ-
ent data from the patient or the family, since, 'they felt, the psychiatrist
would be in the best position to have the full information.) (p. 22).
It is important to note that the conclusions derived were based only
on cases in which the patient had been released; cases in which the hospital
had denied release were not included in the study.
In the release process at Napa State Hospital, as we have described it
above, it appears that study of the "structured strain" must include analy-
sis of all the cases considered at staff conferences, and not just those
that are passed on favorably, for it appears that in denial of release the
hospital's formal power is most clearly expressed. Any case in which the
hospital-staff approved the patient's release would, it seems likely,
involve a specific "'plan" which was at least minimally acceptable to the
hospital.
The Concept of Triangularity
The release process at Napa State Hospital is difficult to describe
in terms of a triangular relationship. In the first place, the patient's
family as "actor" often consists of more than one set of relatives, perhaps
in conflict withseach other. This was quite apparent in a recent case
where the mother was violently opposed to continued hospitalization of the
patient (a possibly suicidal depressed case), whereas the husband agreed
with the hospital staff that further treatment in the hospital was very
necessary. On the other hand, in many cases the patient's relatives are
entirely neutral or uninvolved in the decision-making process itself.
(Relatives of patients seldom appear at the staff conferences,)   In the
mends staff conference of August 26, 1957, for example, mention of the
relatives' attitudes was made in only 4 of the 12 cases considered for
release, and in only one of these cases was-the family actively seeking the
patient's release. From this it appears that the release process is most
often structured as a relationship between the patient and the hospital
staff, with the attitude of family members serving only as additional infor-
mation for the primary decision-makers.
The hospital, too, is not always describable as a single 'tactortt in the
sense apparently intended by Simmons.  Members of the psychiatric staff may
disagree concerning a patient, and the opinions and activities of the psy-
chologists and social workers add still more complexity to the position of
the hospital regarding the patient's leave planning. It can also happen
that a leave plan approved by the therapeutic staff is vetoed by the admin-
istrative heads. This action is most likely to occur in the case of a
patient who has a record of violent anti-social behavior.
Staff Conference and Socio-cultural Norms
An important aspect of the staff conference procedure is the judgment
of "normal" or acceptable behavior.  In their diagnoses and in decisions
concerning release of patients, the hospital staff members assess whether
the patient has engaged in psychiatrically ttabnormal"t behavior,, and attempt
to gauge whether or not the patient is likely to engage in future behavior
contrary to the social and psychiatric norms.  In these cases the staff must
also estimate the amount of tolerance for ttabnormal't behavior in the
patient's prospective home community.. Thus, some patients may be released
from the hospital while they are still considered psychotic, provided the
staff feels that they are not dangerous and that family and community will
tolerate their behavior. Some members of the staff have expressed the
opinion that Negro communities are particularly tolerant toward behavioral
aberrations. An important question for investigation would be whether such
tolerance, if It exists, is due to "open-mindedness"l toward mental illness
or simply an expectancy of "ornery," "contraryKt or-unpredictable behavior
as part of hhealthylt and natural human actions
Staff Conference as a Hub of Communications
In the study of hospital social structure a great deal of attention
has been paid to problems of communications0  (See, for example, Stanton
and Schwartz, 195h)   So far, however  not much attention has been paid to
the staff diagnostic and release conferences as communication processes.
We have noted above that these sessions bring together physicians, psychia-
trists, residents, psychologists, social workers, and other hospital person-
nel for decision-making which Is crucial for the purpose of the institution.
Since the formal power of the hospital vis-A-vis both patient and com-
munity is most clearly exercised in the conference setting, the competition
for prestige among factions in the hospital, If such exists, might be
profitably studied at the'staff conferences. The introduction of large-
scale use of psychiatric drugs, of concepts of the "therapeutic community,"
and other innovations have made the hospital the scene of very rapid change,
and the cleavages that occur between "progressives" and "conservatives," or
other kinds of factions, may be expressed rather clearly in consideration
of particular cases. For example, in a recent release conference a lively
discussion took place over whether a certain rather "poor risk" should be
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released  since she had promised that she would seek private psychiatric
care at Aome. After the patient had been interviewed the chairman informed
the conference that the administration (the Superintendent, Assistant
Superintendent, and the Director of Clinical Services) would be very scep-
tical about letting this patient go home, since the community had been so
upset by her previous relapses, which involved near-riots with the neigh-
bors. At this point two doctors stated that they felt she should stay in
tht hospital. The discussion continued as follows:
Dr. Carter: "But her point is; what are we doing for her?"
Dr. Means and others:  "We may not be doing anything for her, but we are
doing something for the community in keeping her here.tt
Dr. Day: "I think we should let her go."
Dr. Yates: T"I think she should go out--but we must make sure she gets
treatment" (as she had promised).
Dr. Carter: "We must remember that she was a successful businesswoman
for twelve years."I
The staff recommended release, and referred the decision to the
administrative officers for approval.  The administrators approved.  In
this case it appears that there was conflict between the concept of the
hospital as "patient-centered" and the older attitude of the primary respon-
sibility of the hospital being for the protection and convenience of the
outside community.
Summary
(1) The release process involves conflicts between factorsu; these
conflicts have been described by one research group as triangular situations
producing "structured strain," In our Napa State Hospital material, however,
it appears more feasible to describe the action as involving a superordinate-
subordinate relationship between hospital and patient, with the patient's
family playing an important role in only a minority of cases.
(2) In staff conferences, estimates must be made about norms of be-
havior and thresholds of tolerance to deviant behavior in various communities.
Differences in attitudes among sub-cultures and perceptions of these cultural
differences by staff members could be an important area of study.
(3) The staff conferences are an important center of interdepartmental
communication, concerned with transmission of opinions that are made the
basis for immediate action in concrete cases. Intra-staff differences of
opinion and resolution of these differences may be more apparent in the re-
lease conferences than in communication not as immediately involved with
disposition of patients. It should be noted also that staff conferences
may be an important means of communication with the patient.
The research possibilities that have been suggested here would natur-
ally involve investigation of many other phases of hospital operation
besides the release and diagnostic procedure, but a well-rounded study of
modern mental hospital functioning should certainly include consideration
of these staff conferences.
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ENDNOTES
(1) The writer wishes to thank the administrative staff of Napa State
Hospital for financial support and cooperation in this research project.
Thanks are also extended to the staff members at all levels, and to the
patients, for their assistance.
(2)  The important changes taking place in state mental hospitals may also
directly affect the structure and functioning of the staff conferences.
This is borne out by the following excerpts from a letter (Sept* 3,
1957) written by the administrative heads of Napa State Hospital when
they were asked to comment on this paper.
s 0 v we would not like you to take away the impression that we
think the present conference procedure is an ideal one. Much of
this procedure arises from the fact that physicians, social workers,
and other professional personnel have very large case loads. Even
though the professional staff is growing rapidly, we still have
physicians with case loads of 200 and 300. The point of this is
simply that if a psychiatrist has a small number of patients he can
be more intimately aware of each patient's individual problems and
more of the planning for release would originate with the physician
himself*
The second point is that in state hospitals in general there is
an increasing tendency to do away with the formal conference pro-
cedure, with more and more problems of this type being handled in
individual wards by consultation between the ward personnel and the
chief of service* . . it
A transition from staff conference to less formal handling of the
release process would be an important area for future researchO
(3) Fictitious names have been used for all persons referred to in this
study,
(4) We excluded such cases as alcohol and narcotic addictions, in which the
discharge process is usually automatic at the end of a 60- or 90-day
commitment.
(5) Family Care homes are private homes inspected, licensed and paid by the
state to provide a temporary home for released mental patients.
(6) Leave of Absence is the most common type of release for patients who
have been diagnosed as psychotic cases. The patient is allowed to go
home, but remains in the hospital records.  If further hospitalization
is indicated the patient may be re-admitted without formal commitment
procedure.,
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BIBLIOGRAPHY
Caudill, William, Fredrick C. Redlich, Helen R. Gilmore and E. B. Brody
1952   Social structure and interaction processes on a psychiatric
ward. American Journal of Orthopsychiatry 220314-334.
Opler, Marvin K.
1957   Schizophrenia and culture.  Scientific American 197, No. 2:
103-1120
Simmons, Ozzie G., James A. Davis, and Katherine Spencer
1956   Interpersonal strains in release from a mental hospital.
Social Problems h:21-28.
Stanton, Alfred H. and Morris S. Schwartz
1954   The Mental Hospital.  New York, Basic Books.
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